HICS 259 - HOSPITAL CASUALTY / FATALITY REPORT

1. Incident Name / 2. Operational Period (# )
DATE: FROM: ______TO: ______
TIME: FROM: ______TO: ______
3. Number of Casualties / Fatalities
Adult / Pediatric (<18 yrs old) / Total / Comments
Patients seen
Admitted
Critical Care
Medical / Surgical
Other
Other
Other
Discharged
Transferred
Morgue
Waiting to be seen
4. Prepared by / PRINT NAME: ______
DATE/TIME: ______/ SIGNATURE: ______
facility: ______

HICS 259 | Page 1 of 1

HICS 259 - HOSPITAL CASUALTY / FATALITY REPORT

Purpose: The HICS 259 - Hospital Casualty/Fatality Report is used to record the total

numbers of adult and pediatric patients seen, admitted (by bed type), discharged,

transferred, expired, and waiting to be seen for each operational period.

origination: The HICS 259 is prepared by the Planning Section Patient Tracking Manager or team prior

to the Operations Briefing in the next operational period.

copies to: Copies are distributed to the Command Staff, Section Chiefs, and the Documentation

Unit Leader.

Notes: If additional pages are needed, use a blank HICS 259 and repaginate as needed.

Additions may be made to the form to meet the organization’s needs.

NUMBER / TITLE / INSTRUCTIONS
1 / Incident Name / Enter the name assigned to the incident.
2 / Operational Period / Enter the start date (m/d/y) and time (24-hour clock) and end date and time for the operational period to which the form applies.
3 / Number of Casualties / Fatalities
Patients seen / Enter total number of patients seen in either the adult or pediatric column.
Admitted / Enter total number of patients admitted in either the adult or pediatric column.
Critical Care / Enter total number of patients admitted in either the adult or pediatric column.
Medical / Surgical / Enter total number of patients admitted in either the adult or pediatric column.
Other / Enter other needed categories (i.e., burn, pediatric, labor and delivery, forensic, psychiatric) in either the adult or pediatric column.
Discharged / Enter total number of patients discharged in either the adult or pediatric column.
Transferred / Enter total number of patients transferred in either the adult or pediatric column.
Morgue / Enter total number of patients expired in either the adult or pediatric column.
Waiting to be seen / Enter total number of patients still waiting to be seen by physician in either the adult or pediatric column.
4 / Prepared by / Enter the name and signature of the person preparing the form. Enter date (m/d/y), time prepared (24-hour clock), and facility.

HICS 2014